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FROM : West Hazmat FAX NO. : 19166388613 Jul. 21 2003 1,'.:39PM P1 <br />07/21/2003 11:46 2UJJ-1 I8 AGF STnCKTnN -1AGL 01/01 <br />San Jna uin Count F_rtvironmentai Health Department U..n...i_t. Iv. Well <br />Permit Application Suppl9morrt <br />r ._ <br />JOB ADDRESS:_.l �ri6 41�l W17 - PERMIT SR#.—._.__.,... <br />LICENSED CONTRACTORS DECLARATION (Lr <br />I hemby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of Divibion <br />3 of the Suninons and Professions Code and my license ifs in hall force and effect <br />License #: p / ��f.C,U ----------- �Airat�X7atra: _.. i�:✓ y .✓��'�� <br />nate. 1 16, 3 Cantr;3rMr. <br />Signa{tur�t-�— Title: <br />Printed name,. -- 1cM40-0 <br />WORKERS' COMPENSATION DECI.,ARATION <br />I herwhy affirm under penalty of perjury one of the following declaretlons: (CHECK ONE) <br />I have and will maintain a certificate of consent to self4risure for workers' compensation, as provided fi,r <br />by Sedon 3700 of the I-Abor Code, for the pertbrmanuu of they work for which this permit is issued. <br />lave and will maintain workers' compenarltion insurance. as requhud by Section 3700 of the Labor Gude, <br />for the performance of the work for which this permit Is issued. My workcx-x' c:nmpensation insurance <br />rArrier And policy numbers ares: <br /> ri <br />I certify that in the performance of the work for which this iwrrrtit is Iss;uud, I aheil not employ any person in � <br />any manner Yw as to became subject to the workers' compensation lawn; of Califomia, and agree that if I <br />should become �zubjec:t to the workers' cornpensatlon provisions of Section 3700 of the Lal;iW-1 ede^, i sr all <br />forthwith comply/with those pmAsions' <br />Date: �r/L�- 51Ign3rtttttr - 4� l� �/r <br />Printed Name:acN.+ a /� r ir,rr <br />WAkNING., FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL. SUWE--T <br />AN EMPLOYER TO CRIMINAL PENALTIES AND CIViL FINIS UP TO ONE HUNDRED THOUSAND 001 J-AR3 <br />(W0,000.), IN AODITION TO TH[ COST OF COMPENSAr1ON, INTEREST, AT ORNEWS REFS, AND DAMAGES AS <br />PROVIDED FOR IN SEC11ON 3706 OF THE I AMOR511 - <br />AUTHORIZATiOrR'iM <br />N 1=O AN C-57 SIGNING PERMIT APPLICATION <br />t ,_ .(si mature ofC-57 licensed ikuthurized reprecentath a), <br />are authorize (print naatej d d �if !t. t�F /a v r�,� ice, 6e'y.�✓//u u •�• Z - <br />to sign this Han Joaquin county Well Permit Application on my buhalf. I understand this autburizatrort is vatld fu <br />one (1) year and &t limited to the work pian dated on thr front pap* of thta application. <br />"9-021 Ali <br />